Purpose: The objective of this study was to identify gaps in and to improve the falls prevention strategy (FPS) of an inpatient rehabilitation facility (IRF) in Toronto, Canada. Design: A modified version of the Stanford Biodesign Methodology was used. Methods: Chart reviews, a focus group (n = 8), and semistructured interviews (n = 8) were conducted to evaluate the FPS. Findings: Admission Functional Independence Measure score, age, and gender significantly correlated with risk for a fall. The tool used at this IRF was not effectively capturing patients who were at high risk for falls. All healthcare providers interviewed were knowledgeable of fall risks; however, a patient's fall risk status was rarely discussed as a team. Conclusions: The findings informed recommendations to improve the overall FPS at this IRF. Clinical Relevance: Staff may require more coaching for implementing preventative measures/ensuring accountability and evaluating whether current strategies work. These insights can guide improvement initiatives at similar facilities elsewhere.

Our experience provides further evidence to support the safety and effectiveness of the 1064-nm Nd:YAG laser in the management of large and surgically challenging GVMs.